SCHEDULE APPOINTMENT

Welcome! Thank you for trusting us with your dental needs.

FirstFirst

LastLast

MIMI

PreferredPreferred

SexSex

Marital Status:

Age

SSN

AddressStreet

(City/St)(City/St)

ZipZip

E-mail Address

Home Phone:

Cell Phone:

Work Phone:

Patient’s Employer:

Occupation:

Spouse’s Name:

DOB:

SSN:

LEASE COMPLETE SECTION BELOW IF PATIENT IS A MINOR OR STUDENT

Father’s Name:

DOB:

SSN:

Home Address:

City/State/Zip:

Home Phone:

Cell Phone:

Work Phone:

Mother’s Name:

DOB:

SSN:

Home Address:

City/State/Zip:

Home Phone:

Work Phone:

EMERGENCY CONTACT INFORMATION (Name of person not living with you)

Name:

Relationship to patient:

Phone:

DENTAL INSURANCE

Primary Dental Ins Co.:

Secondary Dental Ins Co.:

Policy #:

Policy Holder’s Name:

Policy Holder’s Employer:

Policy Holder’s SSN:

Policy Holder’s DOB:

Relationship to Patient:

Last

First

DATE

Medical History

Please check any allergies that may apply:

Are you under any medical treatment now?YesNO

Are you currently seeing a cardiologist for anything? Whom?YesNO

Do you have or have you had cancer? Type?YesNO

Have you had joint replacement therapy? Knee/Hip/Shoulder?YesNO

Do you take medication for emotional problems?YesNO

Have you ever been told to take antibiotics before a dental appointment?YesNO

Please give the name of the Surgeon who performed your joint replacement as well as the date that the replacement was performed.YesNO

Are you in good health at this time?YesNO

Do you have problems with prolonged bleeding after extractions or surgery?YesNO

Do you have problems with your thyroid gland?YesNO

Do you take Bisphosphonates? (examples: Boniva, Fosamax, Actonel, Reclast)YesNO

Are you now or do you have any reason to believe that you are positive for HIV virus (AIDS)?YesNO

Women, are you Pregnant? Months? Doctor?YesNO

Women, are you breastfeeding?YesNO

Please list any medications you are currently taking

Consent:

The undersigned hereby authorizes Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I have read, understand and agree to the above terms and conditions.

Date

FINANCIAL POLICY

Thank you for choosing our office as your dental healthcare provider. We are committed to providing you with the highest quality lifetime dental care so that you may attain optimum oral health. The following is a statement of our financial policy, which we require that you read, agree to, and sign prior to any treatment. Payment is due at the time service is provided. If you would like more information about our payment options, please speak to a member of our office staff. Please note: Returned checks will be subject to additional fees. In the case it becomes necessary for our office to enlist a collection service, you will be responsible for any collection charges.

Please Initial:

The parent or guardian who brings a child for their initial visit is responsible for payment independent of what a divorce decree may state. Reimbursement must be between the divorced parents. We will not intervene.

Do You Have Insurance?

Todo Dentitstry is not a participating provider with any dental insurance companies.
We must emphasize that as your dental care provider our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company.
As a courtesy to you we will help you process all of your insurance claims. Please understand that we will provide an insurance estimate to you, however, it is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefits will determine the amount paid. We will, of course, do all we can to make sure your estimate is as accurate as possible. If your insurance company has not made payment within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time.
We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This form instructs your insurance company to make payment directly to our office. In the event that an insurance company will not send payment directly to us, payment in full is due at the time services are rendered. • We ask that you pay the deductible and co-payment, which is the estimated amount, not covered by your insurance company, by cash, check, credit card or patient financing at the time we provide the service.
We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over your claim. We thank you for the opportunity to serve your dental health care needs and welcome any questions you may have concerning your care or our financial policy

Consent

I have read, understand and agree to the above terms and conditions. I authorize my insurance company to pay my dental benefits directly to my dental office. I understand that responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I further understand that a finance and/or collection charge will be added to any overdue balance. By signing below, your are authorizing us to call you at any number you provide including calls to mobile/cellular or similar devices for any lawful purpose. You agree to any fees or charges that you may incur for an incoming call and/or text message from us, and/or outgoing call to us, to or from any such number, without reimbursement from us.

Please note that electronic communications inititated by Todo Dentistry will not be used for solicitation. By checking the boxes below, I choose to opt out of the following electronic communications:

CheckboxI DO NOT wish to receive email reminders.I DO NOT wish to receive text message reminders.

Date

Todo Dentistry

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

You May Refuse to Sign This Acknowledgement

I have received a copy of this office’s Notice of Privacy Practices.

(Please Print Name)

(Date)

Please list below the names of any individuals that you authorize Todo Dentistry to speak
with regarding your dental health and/or account information.

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained cause:Individual refused to signCommunication barriers prohibited obtaining the acknowledgementAn emergency situation prevented us from obtaining acknowledgementOther (Please Specify)

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SCHEDULE APPOINTMENT

LEASE COMPLETE SECTION BELOW IF PATIENT IS A MINOR OR STUDENT

EMERGENCY CONTACT INFORMATION (Name of person not living with you)

DENTAL INSURANCE

Medical History

Please check any allergies that may apply:

Consent:

FINANCIAL POLICY

Do You Have Insurance?

Consent

Todo Dentistry

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

You May Refuse to Sign This Acknowledgement

For Office Use Only

Information

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SCHEDULE APPOINTMENT

LEASE COMPLETE SECTION BELOW IF PATIENT IS A MINOR OR STUDENT

EMERGENCY CONTACT INFORMATION (Name of person not living with you)

DENTAL INSURANCE

Medical History

Please check any allergies that may apply:

Consent:

FINANCIAL POLICY

Do You Have Insurance?

Consent

Todo Dentistry

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**

For Office Use Only

Information

Quick Links

Join Our Newsletter

Share on social

You May Refuse to Sign This Acknowledgement